Provider Demographics
NPI:1790381291
Name:SMITH, MADISON ROSE (PT, DPT)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 PADDOCK DR
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-3847
Mailing Address - Country:US
Mailing Address - Phone:864-350-2129
Mailing Address - Fax:
Practice Address - Street 1:25101 N LAKE PLEASANT PKWY
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-1386
Practice Address - Country:US
Practice Address - Phone:623-471-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCP032994T225100000X
AK191351225100000X
MD225100000X
IN225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist